Tuesday 18th November 2008
Very obese, or bariatric, patients are weighing heavily on the NSW health system – and posing risks to nurses. Nurses say we need specially-designed systems, equipment, even room sizes, to deal with this growing problem.
Earlier this year a 240-kilogram Queensland woman was waiting for urgent transport to hospital. Too big for an ambulance, she also exceeded the weight capacity of a standard medivac aircraft, which can only take patients up to 150 kilos. She had to be transported to hospital in a Royal Australian Airforce Transport plane.
Closer to home, a NSW patient was too heavy to be weighed on conventional scales and had to be weighed on the scales of a loading dock via a forklift.
Australia’s increasing waistline is expanding so fast that health facilities are left struggling to keep up. There are 1.13 million obese people in NSW, and the numbers are growing by 15,000 people every year.
Bariatric patients are weighing heavily on the NSW health system. The number of obese admissions have sky-rocketed in the past eight years. At Manning Base Hospital there were 37 obese patients admitted in 2001, compared to this year where the hospital has already admitted 265 obese patients. That’s a seven-fold increase in seven years.
One of the most difficult aspects of managing bariatric patients is mobility and manual handling. Many hospitals simply weren’t designed with obese patients in mind. The size of rooms, especially bathrooms, are often simply too small to fit bariatric patients.
The NSWNA, working with Australasian Health Facility Guidelines, is lobbying to have every new and renovated facility include bariatric-sized bathrooms and equipment.
Obese patients can present a higher risk to staff because they are harder to move and need special equipment.
Maggie Roden, an RN at Lismore Base Hospital, deals with obese patients every day. A few years ago she sustained a shoulder injury while trying to move a semi-conscious woman who weighed about 140 kilos.
‘We were turning her over and her leg fell off the bed. I went to grab the leg, but with the weight and the angle it was at, I strained my shoulder, and that took time to heal,’ she said.
Manning Base Hospital has set up a system to help nurses manage obese patients.
‘The most important thing is to have systems in place,’ says Eddie Wood, the manual handling coordinator at the hospital.
‘The system must be easy to follow. We have a simple flagging system that’s compatible with nurses.’
The hospital has had no manual handling injuries for staff working with obese patients in the past eight years.
‘Once you’ve got systems to deal with obese patients and it’s supported by management, you can manage the problem. If you don’t know what you’re getting, you can’t manage it.’
The problem is that not all hospitals have specific systems to help deal with obese patients. It’s important, for example, that nurses know the weight capacities of beds, slings, and wheelchairs to avoid accidents.
‘Sometimes a patient will present to a small 30-bed hospital, and that patient could weigh over 200 kilos, but the staff may not know the weight capacity of the beds,’ said Eddie. ‘So the bed maybe can’t take the weight of the patient, and that puts both the staff and the patient at risk.’
In some areas, patients who are over a certain weight range are automatically transferred to larger hospitals that have the equipment and capacity to manage them.
NSW Health recommends that staff develop a manual-handling plan for each bariatric patient, taking into account their age, physical condition, low exercise tolerance, medical condition and their psychological wellbeing, including fear and anxiety.
Bariatric patients usually have more health problems and more complicated disease interactions, and so delivering care is rarely straightforward.
‘Obese patients tend to have more co-morbidity,’ said Maggie Roden. ‘They might present at the hospital with cellulitis because of poor circulation to the skin, but then in the course of their treatment other problems are discovered.’ Obesity is linked with a range of health conditions including hypertension, heart disease, increased cancer risk, sleep apnoea, renal disease, and mental health problems including depression.
‘Malnutrition is also associated with obesity, and that’s a concern. But the education isn’t getting out there that obese people can be malnourished. Their diet is often very high energy, low nutrition – processed food, sugary drinks, and there are actually not a lot of nutrients in there.’
The complications of obesity often translate into extra work for nurses. ‘Cannulating can be a real problem,’ said Maggie. ‘It can be very time consuming, and sometimes you have to get doctors involved. Inserting central lines can be difficult, sometimes you can’t get venous access.’
These problems mean bariatric patients often need a higher level of care. At Manning Base Hospital, one patient weighing 188 kilos required 96 staff attendances every day. By the end of her six-month stay in hospital, she’d received 10,912 staff attendances.
While most people understand that obesity is a serious health concern, the cause is often overlooked.
‘Obesity is an eating problem that has a massive impact on the health system and the patient’s quality of life,’ said Maggie. ‘So we can help them by referring them to a dietician. If we had an anorexic patient we would automatically refer them to a dietician – it should be the same for anyone with obesity.’
She adds that it’s important to treat the situation with appropriate sensitivity. ‘When you’re talking to the patient you need to be aware of how you approach the issue so they don’t take offence. It’s quite a sensitive area for some people, but at the same time it’s a real health concern.’
With all the extra issues that bariatric patients can bring, it’s easy to overlook the fact they are people who can sometimes use a little encouragement and support.
‘We had a long-term patient who was morbidly obese with multiple problems, and when they were discharged I really wondered how this person was going to survive on their own. But then the patient came back a few months later, and they’d really improved – they’d started walking, their mentality was so much better,’ said Maggie.
NSW Health has recently launched a $36 million campaign to help educate people about obesity, which includes launching a NSW Health Advice telephone service.
Nurses, too, can have a key role in helping to educate bariatric patients to improve their lives, said Maggie.
‘You can help bariatric patients by encouraging them to do as much as they can while they’re admitted. For some reason, there’s an education gap that’s just not reaching some people, and nurses can really help bridge that gap.’